Cognitive behavioural therapy for bulimia nervosa and related bulimic eating disorders

![CDATA[Cognitive behavioural therapy (CBT) is the only current treatment in eating disorders that can confidently claim a Level 1 evidence base (NICE, 2004). The target patient group for CBT is those patients who suffer from behaviours such as binge eating (objectively large episodes of overeating associated with a sense of loss of control) and/or extreme weight-control behaviours including self-induced vomiting, misuse of laxatives or diuretics ('water tablets'), unusually intense exercise for reasons of weight and shape, and severe restrictive dieting or fasting, in association with very high concerns about weight and shape that are characteristic of an eating disorder. In current diagnostic schemes these include people with bulimia nervosa, and 'eating disorders not otherwise specified' (EDNOS) of a bulimic type. The latter have bulimic behaviours that fail to reach the frequency or severity required for a diagnosis of bulimia nervosa; for example they have subjective bulimic episodes bingeing on small amounts of food (American Psychiatric Association (APA), 1994). CBT may also be used for people with binge eating disorder with some modifications as, by definition, extreme weight-control behaviours are not regularly used by this group (APA, 1994; Fairburn, Marcus, & Wilson, 1993). CBT has also been developed for anorexia nervosa. Some patients may suffer from one or more of these behaviours but primarily have another psychological problem, such as borderline personality disorder. While aspects of CBT may be helpful to these patients, it would not in itself be a primary or sufficient therapy. Finally, some people may engage in extreme weight-control behaviours but they do not cause concern or distress and are not associated with an extreme fear of weight gain or overriding weight and shape concerns in the person's life. For example, jockeys may engage in laxative or diuretic misuse to reduce their weight prior to a race. Education about the harmful consequences of their behaviour is usually sufficient 'therapy' for this group. The present chapter will first discuss the theoretical rationale for CBT and its evidence base in bulimia nervosa and related bulimic eating disorders, and then outline the essential features of CBT for the practitioner. This follows closely the Fairburn model of CBT for bulimia nervosa (CBT-BN; Fair­ burn, 2002) but includes some recent developments and additional features used by an author. The chapter concludes with an overview of limita­tions and challenges in CBT.]]